Pneumonia is a leading cause of illness and death in Nepal, particularly among young children and the elderly. This PowerPoint presentation provides a comprehensive overview of pneumonia in Nepal, including the causes, symptoms, risk factors, and treatment options.
Through powerful images and personal stories, we showcase the impact of pneumonia on individuals, families, and communities in Nepal. We highlight the challenges of accessing healthcare in remote and impoverished areas, the lack of awareness and education about the disease, and the importance of early diagnosis and treatment.
The presentation provides detailed information about the various types of pneumonia and the risk factors associated with each. We also discuss the diagnostic procedures, including chest x-rays and blood tests, and the treatment options, such as antibiotics and oxygen therapy.
In addition, we explore the efforts being made to prevent and control pneumonia in Nepal. We highlight the importance of vaccination, particularly among children and high-risk groups, and the role of community-based interventions in improving access to healthcare and promoting healthy behaviors.
Through this PowerPoint presentation, we aim to raise awareness about pneumonia in Nepal and the importance of early diagnosis and treatment. We showcase the latest research and innovations in pneumonia prevention and treatment, and the importance of collaboration and partnership to address the disease.
We urge the audience to take action in the fight against pneumonia, whether it be through spreading awareness, supporting organizations working on the ground, or advocating for policy change. Let us come together to create a world where no one has to suffer from the devastating effects of pneumonia.
3. Pneumonia:
Pneumonia is a inflammation and consolidation of lungs tissue due to an
infectious agent.
• Pneumonia is frequently categorized based on site of acquisition.
• ●Community-acquired pneumonia (CAP) refers to an acute infection of the
pulmonary parenchyma acquired outside of the hospital.
• ●Nosocomial pneumonia refers to an acute infection of the pulmonary
parenchyma acquired in hospital settings and encompasses both hospital-
acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP).
• •HAP refers to pneumonia acquired ≥48 hours after hospital admission.
• •VAP refers to pneumonia acquired ≥48 hours after endotracheal
intubation.
4. • Pneumonia causes inflammation in the alveoli
• Alveoli are filled with fluid or pus, making difficulty to breathe.
• Affects alveoli rather than the bronchi
• CONSOLIDATION:
Inflammatory induration of a normally aerated lung due to the
presence of cellular exudative in alveoli
• More Likely to occur due to:
• immunocompromised
• potent microbe
5. Anatomical classification
• Bronchopneumonia(patchy inflammation of multiple lobes)
• Lobar pneumonia(involves one or more lobe)
• Interstitial pneumonia(inflammatory inflitrate of alveolar wall)
Etiological classification
• Bacterial infection
• Viral infection
• Fungal infection
7. Incidence.
• It is a major cause of morbidity and mortality with an incidence of 20-
30% in the developing countries and 3-4% in developed countries.
Since pneumonia is not a reportable illness its incidence is based on
crude estimates. It is estimated that Nepal, India, Bangladesh and
Indonesia account for 40% of global acute respiratory infections.In
Nepal, pneumonia and enteric fever was found to be the main cause
of fever.
• Mortality ranges from about 5-35% with a worse prognosis in older
people, men, and people with chronic disease.
• Despite the advances in diagnostic techniques, in approximately 50%
of the cases, etiology is not found
8. Risk factors
• Old age population
• Imunocompromised
• Chronic diseases:COPD, Asthma, DM, Chronic heart disease, HIV
• Viral respiratory tract infection
• Impaired airway protection
• Smoking and alcohol overuse
• Lifestyle: crowded area, low income , homeless, exposure to
environmental toxins
• Malnutrition
9. Etiology(Causes)
• Streptococcus pneumoniae (pneumococcus) and respiratory viruses but
in most of cases no pathogens are detected
• Most identified causes:
• Typical bacteria Atypical
• S. pneumoniae (most common) legionella spp
• Haemophilus influenzae Mycoplasma pneumoniae
• Moraxella catarrhalis chlamydia pneumoniae
• Staphylococcus aureus Chlamydia Psittaci
• Group A streptococci
• Pseudomonas Coxiella Burnetii,
10. Cont.
Respiratory viruses
• Influenza A and B viruses
• Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
• Other coronaviruses (eg, CoV-229E, CoV-NL63, CoV-OC43, CoV-HKU1)
• Rhinoviruses
• Parainfluenza viruses
• Adenoviruses
• Respiratory syncytial virus
30. Prevention
The three primary pillars for the prevention of CAP are
• Smoking cessation (when appropriate)
• Influenza vaccination for all patients
• Pneumococcal vaccination for at-risk patients
35. Treatment
The most important aspects of management include
• oxygenation,
• fluid balance and
• antibiotic therapy.
• In severe or prolonged illness, nutritional support may be required.
36. Oxygenation
• Oxygen should be administered to all patients with tachypnoea,
hypoxaemia, hypotension or acidosis with the aim of maintaining the
PaO2 ≥ 60 mmHg or SaO2 ≥ 92%
37. Fluid balance
• Intravenous fluids should be considered in those with severe illness,
in older patients and those with vomiting. It may be appropriate to
discontinue hypertensive agents temporarily. Otherwise, an adequate
oral intake of fluid should be encouraged. Inotropic support may be
required in patients with shock
38. Antibiotics:
Uncomplicated CAP
Amoxicillin 500 mg 3 times daily orally
If patient is allergic to penicillin
Clarithromycin 500 mg twice daily orally or Erythromycin 500 mg 4 times
daily orally
If Staphylococcus is cultured or suspected
Flucloxacillin 1–2 g 4 times daily IV plus Clarithromycin 500 mg twice daily IV
If Mycoplasma or Legionella is suspected
-Clarithromycin 500 mg twice daily orally/IV or Erythromycin 500 mg 4 times
daily orally/IV plus
-Rifampicin 600 mg twice daily IV in severe cases
39. Cont..
Severe CAP
• Clarithromycin 500 mg twice daily IV or Erythromycin 500 mg 4 times
daily IV plus
• Co-amoxiclav 1.2 g 3 times daily IV or Ceftriaxone 1–2 g daily IV or
Cefuroxime 1.5 g 3 times daily IV or
• Amoxicillin 1 g 4 times daily IV plus flucloxacillin 2 g 4 times daily IV
Physiotherapy:
40. Cont.(for knowledge)
• For most patients aged <65 years who are otherwise healthy and have
not recently used antibiotics, we typically use oral amoxicillin plus a
macrolide (eg, azithromycin or clarithromycin) or doxycycline.
Generally, we prefer to use a macrolide over doxycycline
• For patients who cannot use any beta-lactam, we select a respiratory
fluoroquinolone (eg, levofloxacin, moxifloxacin, gemifloxacin)
• or patients who can use cephalosporins, we use a third-generation
cephalosporin (eg, cefpodoxime) plus either a macrolide
or doxycycline.
41. • For most patients without suspicion for MRSA or Pseudomonas, we
treat with a beta-lactam
(eg, ceftriaxone, cefotaxime, ceftaroline, ampicillin-sulbactam,) plus a
macrolide (eg, azithromycin or clarithromycin) or a beta-lactam plus a
respiratory fluoroquinolone (eg, levofloxacin or moxifloxacin)
42. • For patients with known colonization or prior infection
with Pseudomonas, recent hospitalization with IV antibiotic use, or
other strong suspicion for pseudomonal infection, we typically use
combination therapy with both an antipseudomonal beta-lactam
(eg, piperacillin-tazobactam, cefepime(2g
bd), ceftazidime, meropenem, or imipenem) plus an
antipseudomonal fluoroquinolone (eg, ciprofloxacin or levofloxacin).
The selection of empiric regimens should also be informed by the
susceptibility pattern for prior isolates
43. Cont..
For patients with known colonization or prior infection with MRSA or
other strong suspicion for MRSA infection, we add an agent with anti-
MRSA activity, such as vancomycin(15-
20mg/kg/dose) or linezolid(600mg BD)
Others antibiotcs: Aztreonam, carbapenems
STEROIDS:
44. ICU ADMISSION/ indication of referal
• CURB score of 4–5 (see Fig. 17.32), failing to respond rapidly to initial
management
• Persisting hypoxia (PaO2 < 8 kPa (60 mmHg)), despite high
concentrations of oxygen
• Progressive hypercapnia
• Severe acidosis
• Circulatory shock
• Reduced conscious level
49. Hospital Acquired Pneumonia()
• Hospital-acquired pneumonia (HAP) or nosocomial pneumonia refers
to a new episode of pneumonia occurring at least 2 days after
admission to hospital
• . It is the second most common hospital-acquired infection (HAI) and
the leading cause of HAI associated death.
50. Clinical Feature and Investigation
Same as CAP(community accquired pneumonia)
• The diagnosis should be considered in any hospitalised or ventilated
patient who develops
• purulent sputum (or endotracheal secretions)
• new radiological infiltrates(In xray or CT scan)
• an otherwise unexplained increase in oxygen requirement,
• a core temperature > 38.3°C, and
• a leucocytosis or leucopenia
51. Factors predisposing/Causes
Reduced host defences against bacteria
• Reduced immune defences (e.g. glucocorticoid treatment, diabetes,
malignancy)
• Reduced cough reflex (e.g. post-operative)
• Disordered mucociliary clearance (e.g. anaesthetic agents)
• Bulbar or vocal cord palsy
Aspiration of nasopharyngeal or gastric secretions
• Immobility or reduced conscious level
• Vomiting, dysphagia (N.B. stroke disease), achalasia or severe reflux
• Nasogastric intubation
53. Treatment
• The principles of management are similar to those of CAP, focusing on
adequate oxygenation, appropriate fluid balance and antibiotics
• In patients who have received no previous antibiotics, co-amoxiclav or
cefuroxime represents a sensible choice
• If the patient has received a course of recent antibiotics, then
piperacillin/tazobactam or a third-generation
cephalosporin(ceftriazone) should be considered.
• Antipseudomonal cover may be provided by a carbapenem
(meropenem), an anti-pseudomonal cephalosporin or piperacillin–
tazobactam
54. Cont.
• MRSA cover may be provided by glycopeptides such as vancomycin or
linezolid
55. Aspiration pneumonia and Suppurative
Pneumonia
Suppurative and Aspiration Pneumonia are considered together as
clinical feature overlap
is characterised by destruction of the lung parenchyma by the
inflammatory process
develop after the inhalation of septic material during operations on the
nose, mouth or throat, under general anaesthesia, or of vomitus during
anaesthesia or coma, particularly if oral hygiene is poor
Additional risk factors for aspiration pneumonia include vocal cord
palsy, achalasia or oesophageal reflux, and alcoholism
56. Cont.
• The organism(s) isolated from the sputum include Strep.
pneumoniae, Staph. aureus, Streptococcus pyogenes, H. influenzae
57. Clinical features of Aspiration Pneumonia
Symptoms
• Cough with large amounts of sputum, sometimes fetid and blood-
stained
• Pleural pain common
• Sudden expectoration of copious amounts of foul sputum if abscess
ruptures into a bronchus
58. Clinical signs
• High remittent pyrexia
• Profound systemic upset
• Digital clubbing may develop quickly (10–14 days)
• Consolidation on chest examination; signs of cavitation rarely found
• Pleural rub common
• Rapid deterioration in general health, with marked weight loss if not
adequately treated
59. Treatment
• Aspiration pneumonia can usually be treated with amoxicillin and
metronidazole
• MRSA is usually susceptible to a variety of oral non-β-lactam
antibiotics, such as trimethoprim/sulfamethoxazole, clindamycin,
tetracyclines and linezolid, VANCOMYCIN
60. Pneumonia in the immunocompromised
patient
• Patients immunocompromised by drugs or disease (particularly
human immunodeficiency virus (HIV) infection are at increased risk of
pulmonary infection and pneumonia is the most common cause of
death in this group
• low virulence or non-pathogenic, may become ‘opportunistic’
pathogens cause pneumonia
• Depending on the clinical context, clinicians should consider the
possibility of Gram-negative bacteria, especially P. aeruginosa,
viruses, fungi, mycobacteria
• Infection is often due to more than one organism
61. Clinical Feature
• fever,
• cough and
• breathlessness
but are influenced by the degree of immunosuppression
Other similar to other type of pneumonia
62. treatment
• treatment should be based on an established aetiological diagnosis;
• in practice, however, the causative agent is frequently unknown.
• Factors that favour a bacterial aetiology include neutropenia, rapid
onset and deterioration
• broad-spectrum antibiotic therapy should be commenced
immediately, e.g. a third-generation cephalosporin(ceftriazone), or a
quinolone(ciprofloxacin , levofloxacin), plus an antistaphylococcal
antibiotic(amoxicillin), or an antipseudomonal penicillin(piperacillin)
Cough (with or without sputum production), dyspnea, and pleuritic chest pain are among the most common symptoms associated with CAP. Signs of pneumonia on physical examination include tachypnea, increased work of breathing, and adventitious breath sounds, including rales/crackles and rhonchi. Tactile fremitus, egophony, and dullness to percussion also suggest pneumonia. These signs and symptoms result from the accumulation of white blood cells (WBCs), fluid, and proteins in the alveolar space. Hypoxemia can result from the subsequent impairment of alveolar gas exchange. On chest radiograph, accumulation of WBCs and fluid within the alveoli appears as pulmonary opacities
Chest radiograph (A) shows a bilateral reticulonodular pattern. High-resolution computed tomography (CT) image at the level of the main bronchi (B) demonstrates bilateral ground-glass opacities and centrilobular nodules (arrows). High-resolution CT scan at the level of the basal segmental bronchi (C) shows centrilobular nodules (straight arrows), branching opacities (tree-in-bud pattern; curved arrow), ground-glass opacities, small foci of consolidation, and mild thickening of the interlobular septa (arrowheads). The patient was a 20-year-old man with Mycoplasma pneumoniae pneumonia.
Antibiotics are relative to change according to hospital and area of setting